Diabetes Type I in Children

 

Diabetes is a long-term condition that can have a major impact on the life of a child or young person, as well as their family or carers. In addition to insulin therapy, diabetes management should include education, support and access to psychological services

Preparations should also be made for the transition from paediatric to adult services, which have a somewhat different model of care and evidence base

Type 1 diabetes is becoming more common in the UK.  Much of the general care for type 1 diabetes is the same as for type 2 diabetes, although the initial management is different

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Diabetes Type I

Diagnosis

The characteristics of type 1 diabetes in children and young people include:

  • hyperglycaemia (random plasma glucose more than 11 mmol/litre)
  • polyuria
  • polydipsia
  • weight loss
  • excessive tiredness

Refer children and young people with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care

Confirm type 1 diabetes in children and young people using the plasma glucose criteria specified in the World Health Organisation's 2006 report on the diagnosis and classification of diabetes mellitus

When diagnosing diabetes in a child or young person, assume type 1 diabetes unless there are strong indications of type 2 diabetes, monogenic or mitochondrial diabetes

Think about the possibility of type 2 diabetes in children and young people with suspected diabetes who:

  • have a strong family history of type 2 diabetes
  • are obese at presentation
  • are of black or Asian family origin
  • have no insulin requirement, or have an insulin requirement of less than 0.5 units/kg
  • body weight/day after the partial remission phase
  • show evidence of insulin resistance (for example, acanthosis nigricans)

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Education and information

Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis.  Ensure that the programme includes the following core topics:

  • insulin therapy, including its aims, how it works, its mode of delivery and dosage adjustment
  • blood glucose monitoring, including targets for blood glucose control (blood glucose and HbA1c levels)
  • the effects of diet, physical activity and intercurrent illness on blood glucose control
  • managing intercurrent illness ('sick-day rules', including monitoring of blood ketones [beta-hydroxybutyrate])
  • detecting and managing hypoglycaemia, hyperglycaemia and ketosis

Encourage young people with type 1 diabetes to attend clinic 4 times a year because regular contact is associated with optimal blood glucose control

Smoking and substance misuse

  1. Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about general health problems associated with smoking and in particular the risks of developing vascular complications
  2. Offer smoking cessation programmes to children and young people with type 1 diabetes who smoke
  3. Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) about the general dangers of substance misuse and the possible effects on blood glucose control

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Immunisation

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the Department of Health's Green Book recommends annual immunisation against influenza for children and young people with diabetes over the age of 6 months

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Insulin therapy

  1. Offer children and young people with type 1 diabetes multiple daily injection basal–bolus insulin regimens from diagnosis. If a multiple daily injection regimen is not appropriate for a child or young person with type 1 diabetes, consider continuous subcutaneous insulin infusion (CSII or insulin pump) therapy
  2. Explain to children and young people with type 1 diabetes using multiple daily insulin injection regimens and their family members or carers (as appropriate) that injecting rapid-acting insulin analogues before eating (rather than after eating) reduces blood glucose levels after meals and helps to optimise blood glucose control
  3. Provide all children and young people with type 1 diabetes who are starting continuous subcutaneous insulin infusion (CSII or insulin pump) therapy and their family members or carers (as appropriate) with specific training in its use
  4. Offer children and young people with type 1 diabetes a review of injection sites at each clinic visit
  5. Provide children and young people with type 1 diabetes with rapid-acting insulin analogues for use during intercurrent illness or episodes of hyperglycaemia

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Dietary management

  1. Explain regularly to children and young people with type 1 diabetes and their family members or carers (as appropriate) how healthy eating (including eating foods with a low glycaemic index, fruit and vegetables, and appropriate types and amounts of fats) can reduce their risk of cardiovascular disease, and support them to adjust their food choices accordingly
  2. Offer level 3 carbohydrate-counting education from diagnosis to children and young people with type 1 diabetes who are using a multiple daily insulin injection regimen or continuous subcutaneous insulin infusion (CSII or insulin pump) therapy, and to their family members or carers (as appropriate), and repeat the offer at intervals thereafter
  3. Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that a low glycaemic index diet may help to improve blood glucose control and reduce the risk of hyperglycaemic episodes
  4. At each clinic visit for children and young people with type 1 diabetes measure height and weight and plot on an appropriate growth chart. Check for normal growth and/or significant changes in weight because these may reflect changes in blood glucose control

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Exercise advice

Encourage children and young people with type 1 diabetes and their family members or carers (as appropriate) to monitor blood glucose levels before and after exercise so that they can:

  • identify when changes in insulin or food intake are necessary
  • learn the blood glucose response to different exercise conditions
  • be aware of exercise-induced hypoglycaemia
  • be aware that hypoglycaemia may occur several hours after prolonged exercise

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that additional carbohydrate should be consumed if plasma glucose levels are less than 7 mmol/litre before exercise is undertaken

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Blood glucose targets and monitoring

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that the optimal target ranges for short-term plasma glucose control are:

  • fasting plasma glucose level of 4–7 mmol/litre on waking
  • a plasma glucose level of 4–7 mmol/litre before meals at other times of the day
  • a plasma glucose level of 5–9 mmol/litre after meals
  • a plasma glucose level of at least 5 mmol/litre when driving

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that achieving and maintaining blood glucose levels towards the lower end of the target optimal ranges will help them to achieve the lowest attainable HbA1c

Advise children and young people with type 1 diabetes and their family members or carers (as appropriate) to routinely perform at least 5 capillary blood glucose tests per day

Offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have:

  • frequent severe hypoglycaemia or
  • impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety) or
  • inability to recognise, or communicated about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities)

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Consider ongoing real-time continuous glucose monitoring for:

  • neonates, infants and pre-school children
  • children and young people who undertake high levels of physical activity (for example, sport at a regional, national or international level)
  • children and young people who have comorbidities (for example anorexia nervosa) or who are receiving treatments (for example corticosteroids) that can make blood glucose control difficult

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HbA1C targets and monitoring

  1. Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long-term complications
  2. Offer children and young people with type 1 diabetes measurement of their HbA1c level 4 times a year (more frequent testing may be appropriate if there is concern about suboptimal blood glucose control)

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Hyperglycaemia and blood ketone monitoring

Provide each child and young person with type 1 diabetes and their family members or carers (as appropriate) with clear individualised oral and written advice ('sick-day rules') about managing type 1 diabetes during intercurrent illness or episodes of hyperglycaemia, including:

  • monitoring blood glucose
  • monitoring and interpreting blood ketones (beta-hydroxybutyrate)
  • adjusting their insulin regimen
  • food and fluid intake
  • when and where to seek further advice or help

Revisit the advice with the child or young person and their family members or carers (as appropriate) at least annually

Offer children and young people with type 1 diabetes blood ketone testing strips and a meter, and advise them and their family members or carers (as appropriate) to test for ketonaemia if they are ill or have hyperglycaemia

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Hypoglycaemia

Immediately treat mild to moderate hypoglycaemia in children and young people with type 1 diabetes as follows:

  • Give fast-acting glucose (for example, 10–20 g) by mouth (liquid carbohydrate may be taken more easily than solid)
  • Be aware that fast-acting glucose may need to be given in frequent small amounts, because hypoglycaemia can cause vomiting
  • Recheck blood glucose levels within 15 minutes (fast-acting glucose should raise blood glucose levels within 5–15 minutes) and repeat fast-acting glucose if hypoglycaemia persists
  • As symptoms improve or normoglycaemia is restored, give oral complex long-acting carbohydrate to maintain blood glucose levels, unless the child or young person is:
    • about to have a snack or meal
    • receiving a continuous subcutaneous insulin infusion

Treat severe hypoglycaemia in children and young people with type 1 diabetes who are not in hospital or who do not have rapid intravenous access available as follows:

  • Use intramuscular glucagon or a concentrated oral glucose solution (for example Glucogel). Do not use oral glucose solution if the level of consciousness is reduced as this could be dangerous
  • If using intramuscular glucagon:
    • give children and young people over 8 years old (or who weigh 25 kg or more) 1 mg glucagon
    • give children under 8 years old (or who weigh less than 25 kg) 500 micrograms of glucagon
  • Seek medical assistance if blood glucose levels do not respond or symptoms persist for more than 10 minutes
  • As symptoms improve or normoglycaemia is restored, and once the child or young person is sufficiently awake, give oral complex long-acting carbohydrate to maintain normal blood glucose levels
  • Recheck the blood glucose repeatedly in children and young people who have persistently reduced consciousness after a severe hypoglycaemic episode, to determine whether further glucose is needed

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Psychological and social support

NOTE Diabetes teams should be aware that children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties

Offer children and young people with type 1 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs

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Monitoring of complications

Offer children and young people with type 1 diabetes monitoring for:

  • thyroid disease at diagnosis and annually thereafter until transfer to adult services
  • diabetic retinopathy annually from 12 years
  • moderately increased albuminuria (albumin:creatinine ratio [ACR] 3–30 mg/mmol; 'microalbuminuria') to detect diabetic kidney disease, annually from 12 years
  • hypertension annually from 12 years

Be aware of the following rare complications and associated conditions when children and young people with type 1 diabetes attend clinic visits:

  • juvenile cataracts
  • necrobiosis lipoidica
  • Addison's disease

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Diabetic retinopathy

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that:

  • monitoring for diabetic retinopathy begins at 12 years because diabetic retinopathy that needs treatment is extremely rare in children and young people under 12
  • background retinopathy is often found through monitoring, and improving blood glucose control will reduce the risk of this progressing to significant diabetic retinopathy
  • annual monitoring from 12 years is important because, if significant diabetic retinopathy is found, early treatment will improve the outcome

GPs should refer children to the local diabetic eye screening programme before they reach 12 years of age

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Diabetic kidney disease

Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that:

  • monitoring for moderately increased albuminuria (ACR 3–30 mg/mmol; 'microalbuminuria') to detect diabetic kidney disease begins at 12 years because diabetic kidney disease in children and young people under 12 is extremely rare
  • using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria is important, as this reduces the risk of false positive results
  • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease
  • annual monitoring from 12 years is important because, if diabetic kidney disease is found, early treatment will improve the outcome

Use the first urine sample of the day ('early morning urine') to measure the albumin:creatinine ratio. If the first urine sample of the day is not available, use a random sample, but be aware that this is associated with an increased risk of false positive results

If the initial albumin:creatinine ratio is above 3 mg/mmol but below 30 mg/mmol, confirm the result by repeating the test on 2 further occasions using first urine samples of the day ('early morning urine') before starting further investigation and therapy

Investigate further if the initial albumin:creatinine ratio is 30 mg/mmol or more (proteinuria)

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Transition from Paediatric to Adult Care

  1. Agree specific local protocols for transferring young people with diabetes from paediatric to adult services
  2. Base the decision about the age of transfer to the adult service on the young person's physical development and emotional maturity, and local circumstances
  3. Explain to young people with type 1 diabetes who are preparing for transition to adult services that some aspects of diabetes care will change at transition

Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

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